COPD

1. CENTRE FOR PHYSIOTHERAPY AND REHABILITATION SCIENCES,
JAMIA MILLIA ISLAMIA
CHRONIC OBSTRUCTIVE PULMONARY
DISEASE
SUBJECT – PHYSIOTHERAPY IN
CARDIOPULMONARY CONDITIONS (BPT - 402)
SUBMITTED TO – DR JAMAAL ALI MOIZ
SUBMITTED BY – MUBASHIRAH KHANAM
CLASS – BPT, 4TH YEAR
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2. DEFINITION –
• It is a non-reversible progressive disease that is characterized by
symptoms such as shortness of breath, wheezing and a cough that
produces a high volume of secretions which causes airways to become
narrower making it difficult for air to go into and out of lungs.
• Main risk exposure for COPD - tobacco smoking, environmental
exposures (biomass fuel exposure and air pollution) and host factors
(genetic abnormalities, abnormal lung development and accelerated
aging).
• COPD may be punctuated by acute worsening of respiratory symptoms,
called exacerbations or can be stable COPD.
COPD is a common, preventable and treatable disease that is
characterized by persistent respiratory symptoms and airflow limitation
that is due to airway and/or alveolar abnormalities usually caused by
significant exposure to noxious particles or gases.
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3. PATHOLOGY -
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4. The chronic airflow limitation that characterizes COPD is caused by a
mixture of small airways disease and parenchymal destruction.
• The relative contributions of which vary from person to person.
It causes problems with oxygen delivery, which may result in increased
work of breathing and shortness of breath.
A loss of small airways may contribute to airflow limitation and
mucociliary dysfunction.
• A characteristic feature of the disease.
Chronic respiratory symptoms may precede the development of airflow
limitation and be associated with acute respiratory events.
• Chronic respiratory symptoms may exist with normal spirometry and a
significant number of smokers without airflow limitation have structural
evidence of lung disease.
PATHOGENESIS –
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5. FACTORS THAT INFLUENCE DISEASE DEVELOPMENT
AND PROGRESSION –
• Tobacco smoke – prevelence is higher in smokers and ex-smokers
compared to non-smokers. Eg. Cigarette, pipe, cigar, water pipe, Passive
smoking.
• Age and gender - Higher in ≥ 40 years; Male > female
• Genetic factors - genetic susceptibility and deficit in α1-antitrypsin
• Autoimmune disease - any individuals with COPD who have stopped
smoking have active inflammation in the lungs
• Occupational exposure - coal mining, gold mining, and the cotton textile
industry and chemicals such as cadmium, isocyanates
• Air pollution - Wood, animal dung, crop residues, and coal, typically
burned in open fires or poorly functioning stoves, may lead to indoor air
pollution.
• Asthma, airway hyper-reactivity and chronic bronchitis
• Infection - HIV infection
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6. DIAGNOSIS –
• According to GOLD, the diagnosis of COPD requires 3 features –
– A postbronchodilator FEV1/FVC ratio of less than 0.70, which
“confirms the presence of persistent airflow limitation”
– “Appropriate symptoms” including dyspnea, chronic cough, sputum
production, or wheezing.
Dyspnea – progressive over time, characteristically increases
with exercise
Chronic cough – first symptom
Sputum –with any pattern for equal to or more than 3 months in
consecutive 2 years.
Reccurent wheezing
– “Significant exposures to noxious stimuli” such as history of
smoking cigarettes, or other environmental exposures, such as
smoke from home cooking and heating fuel.
• Additional features in severe disease - Fatigue, weight loss and anorexia
are common in patients with more severe forms of COPD. 6

7. • Medical history –
– Exposure to risk factors
– Past medical history, including asthma, allergy, sinusitis, or nasal
polyps
– Family history of COPD
– Pattern of symptom development
– Impact of disease on patient’s life, including limitation of activity
– Presence of comorbidities
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8. ASSESSMENT -
Goals of assessment -
• to determine the level of airflow limitation
• to define its impact on the patient’s health status
• identify the risk of future events (such as exacerbations, hospital
admissions or death)
Classification of severity of airflow limitation –
• Spirometry performed after administration of an adequate dose of one
short-acting inhaled bronchodilator in order to minimize variability.
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9. Assessment of symptoms-
• mMRC Questionnaire
• the COPD Assessment Test (CAT)
• St. George’s Respiratory Questionnaire (SGRQ)
Choice of thresholds -
• SGRQ scores < 25 are uncommon in COPD patients
• The equivalent cut-point for the CAT is 10
• mMRC threshold of ≥ 2 is used to separate “less breathlessness” from
“more breathlessness”.
Assessment of exacerbation risk -
• ≥ 1-2 exacerbations per year including prior hospitalization
• 0 or 1 that don't lead to hospitalizations
Revised combined COPD assessment -
• ABCD assessment tool -
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11. PREVENTION AND MAINTENANCE THERAPY -
• Key is smoking cessation by pharmacotherapy, Smoking cessation
programs and nicotine replacement.
• Pharmacologic therapy can reduce COPD symptoms, reduce the
frequency and severity of exacerbations, and improve health status and
exercise tolerance.
• Influenza and pneumococcal vaccinations decrease the incidence of
lower respiratory tract infections.
• Pulmonary rehabilitation improves symptoms, quality of life, and
physical and emotional participation in everyday activities.
MANAGEMENT OF STABLE COPD –
1. Identify and Reduce Exposure to Risk Factors-
• Cigarette smoking is the most commonly encountered and easily
identifiable risk factor for COPD so smoking cessation should be
continually encouraged for current smokers.
• Reduction of total personal exposure to occupational dusts, fumes, and
gases, and to indoor and outdoor air pollutants, should be addressed.
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12. 2. Pharmacologic therapy for stable copd -
• Bronchodilators - Beta2-agonists, Antimuscarinic drugs
• Combination bronchodilator therapy - LABA and LAMA in a single
inhaler, ICS/LABA
• Anti-inflammatory agents - Inhaled corticosteroids, Oral glucocorticoids
• Antibiotics
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13. 3. Pulmonary Rehabilitation –
• It is a comprehensive intervention based on thorough patient assessment
followed by patient-tailored therapies e.g., exercise training, education,
self-management interventions.
• Aims at behavior changes to improve physical and psychological
condition and promote adherence to health-enhancing behaviors.
• Pulmonary rehabilitation can reduce readmissions and mortality in
patients following a recent exacerbation (≤ 4 weeks from prior
hospitalization) and improves dyspnea, health status and exercise
tolerance in stable patients.
4. Education and self-management –
• Smoking cessation, basic information about COPD, correct use of
inhaler devices, early recognition of exacerbation, strategies to minimize
dyspnea, when to seek help, surgical interventions, and the consideration
of advance directives, are examples of educational topics.
5. Nutritional support -
• For malnourished patients with COPD nutritional supplementation is
recommended. 13

14. 6. Symptom Control –
• The goal is to prevent and relieve suffering, to improve quality of life,
relief of dyspnea, pain, anxiety, depression, fatigue and poor nutrition
regardless of the stage of disease.
7. End of life and Palliative care –
• Patients can become critically ill, so they or their family members may
need to decide whether a course of intensive care is likely to achieve their
goals of care.
• Advance care planning can reduce anxiety for patients and their families.
• Ensure that care is consistent and avoid unnecessary and costly therapies.
8. Ventilatory support –
• NPPV may improve hospitalization free survival in seelcted patients after
recent hospitalization, particularly in those with pronounced daytime
persistent hypercapnia (PaCO2 > 52mmHg).
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15. 9. Oxygen therapy –
Long-term oxygen therapy (> 15 hours per day) is indicated for stable
patients who have-
• PaO2 at or below 55 mmHg or SaO2 at or below 88%, with or without
hypercapnia confirmed twice over a three-week period
• PaO2 between 55 and 60 mmHg, or SaO2 of 88%, if there is evidence of
pulmonary hypertension, peripheral edema suggesting congestive cardiac
failure, or polycythemia.
10. Surgical Intervention therapy –
• Lung volume reduction surgery
• Bullectomy
• Lung transplantation
• Bronchoscopic Interventions to Reduce Hyperinflation in Severe
Emphysema
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16. MONITORING AND FOLLOW-UP-
Management of Exacerbation-
• Most common causes - respiratory tract infections.
• COPD exacerbations are classified as-
– Mild (treated with SABDs)
– Moderate(treated with SABDs + antibiotics and/or oral
corticosteroids)
– Severe(patient requires hospitalization or visits the emergency room)..
COPD and Comorbidities-
• COPD often coexists with other diseases (comorbidities) that may
significantly impact patient outcome.
• The presence of comorbidities should not alter COPD treatment and
comorbidities should be treated per usual standards regardless of the
presence of COPD.
• Cardiovascular disease, osteoporosis, anxiety and depression, metabolic
syndrome and diabetes , bronchiectasis, Obstructive Sleep Apnea.
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17. REFERENCE –
• AJRCCM Articles in Press. Published on 27-January-2017 as
10.1164/rccm.201701-0218PP, Global Strategy for the Diagnosis,
Management, and Prevention of Chronic Obstructive Lung Disease
2017 Report GOLD Executive Summary
• COPD Guidelines: A Review of the 2018 GOLD Report Shireen
Mirza, MBBS; Ryan D. Clay, MD; Matthew A. Koslow, MD; and
Paul D. Scanlon, MD
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